Southland

F-F609

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 18 555070 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555070 B. Wing 03/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Southland 11701 Studebaker Road Norwalk, CA 90650

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45382 potential for actual harm 45777 Residents Affected - Many 50387

Based on observation, interview, and record review, the facility failed to observe infection control measures

on 3 of 5 sampled residents Resident 7, 8, 268 and 7 by failing to:

a. Ensure Certified Nursing Assistant 5 (CNA 5) wore an isolation gown (protective apparel used to protect

the wearer from the transfer of microorganisms and body fluids) while addressing Resident 8's pain concerns which required direct contact with Resident 8 who was on Enhanced Barrier Precautions (EBP, infection control intervention using gown and gloves during high contact resident care activities designed to reduce

the transmission of multi-drug resistant organisms).

b. Ensure Restorative Nursing Aide 1 (RNA 1) and Restorative Nursing Aide 2 (RNA 2) wore isolation gowns while providing RNA exercises to Resident 8 who was on EBP precautions.

c. ensure Resident 268's, peripheral venous catheter (a thin flexible tube inserted into a vein to provide access for giving medications ) hub ( the external part of the catheter that allows for infusing medications and fluids ) was covered with a pressure cap ( a sterile cap placed on the end of an intravenous tubing to minimize the risk of infection entering the blood stream).

d. Donning and doffing properly when Certified Nurse Assistant (CNA) 2, CNA 3, CNA 4, Housekeeping staff (HK) 1, HK 3 entered and exited Resident 26's room, a COVID precaution Room (a special room to isolate patients with COVID-19 minimizing the risk of spreading the virus).Wearing proper personal protective equipment (PPE- such as gloves, masks, or safety glasses) while LVN 1 changing the tube feeding (a method of delivering nutrients directly to the digestive system through a tube) for Resident 7 who had Enhanced Standard Precautions (known as Enhanced Barrier Precautions, EBP, are extra infection control measures, like wearing gowns and gloves, used in addition to standard precautions, to reduce the spread of multidrug -resistant organisms).

e. Put EBP signage in the entrance door of Resident 7's room.

f. Isolate Resident 26 when scabies was identified.

These failures had the potential to transmit infectious microorganisms and increase the risk of infection among the residents and staff members.

Findings:

a. During a review of Resident 8's Admission Record, the Admission Record indicated the facility initially admitted Resident 8 on 6/29/2010 and readmitted Resident 8 on 11/18/210 with diagnoses including urinary tract infection (UTI, an infection in the bladder/urinary tract) and cervical radiculopathy (condition caused by compression and inflammation of nerve roots in the neck which usually leads to pain, numbness, and weakness of the arms).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 18 555070 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555070 B. Wing 03/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Southland 11701 Studebaker Road Norwalk, CA 90650

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During a review of Resident 8's Order Summary Report, the Order Summary Report indicated a physician's order, dated 2/25/2025, for Resident 8 to be on EBP precautions due to the presence of a foley catheter Level of Harm - Minimal harm or (thin, flexible rube inserted into the bladder to drain urine). potential for actual harm

During an observation on 3/11/2025 at 10:14 am, in Resident 8's room, Resident 8 was lying in bed. Residents Affected - Many Resident 8 stated she had pain in the abdominal and buttock area and asked CNA 5 for assistance. CNA 5 put on gloves and did not put on an isolation gown. CNA 5 walked to Resident 8's bed, removed the blankets, touched Resident 8's abdomen and legs, replaced the blankets over Resident 8's body, moved the foley catheter, repositioned Resident 8's call light, removed both gloves, performed hand hygiene, and exited

the room.

During an interview on 3/11/2025 at 10:24 am, CNA 5 stated she did not wear an isolation gown while providing direct care to Resident 8. CNA 5 stated she should have worn an isolation gown while assisting Resident 8 with care because she had direct contact with Resident 8 who was on EBP precautions. CNA 5 stated it was important to follow infection control protocols to prevent the spread of infection.

During an interview on 3/12/2025 at 10:14 am, the Infection Preventionist Nurse (IPN) stated the purpose of EBP was to reduce the transmission of Multi-Drug Resistant Organisms (MRDO, bacteria resistant to many antibiotics). The IPN stated all staff providing direct patient care for residents on EBP precautions must wear

the appropriate personal protective equipment (PPE, equipment worn to minimize exposure to hazards that can cause serious injuries and illnesses) which included an isolation gown and gloves to prevent the spread of infection and reduce the transmission of MRDO.

During an interview on 3/14/2025 at 1:27 pm, the Director of Nursing (DON) stated it was important all staff followed the proper infection control protocols to prevent the spread of infection.

b. During a review of Resident 8's Admission Record, the Admission Record indicated the facility initially admitted Resident 8 on 6/29/2010 and readmitted Resident 8 on 11/18/210 with diagnoses including UTI and cervical radiculopathy.

During a review of Resident 8's Order Summary Report, the Order Summary Report indicated a physician's order, dated 2/25/2025, for Resident 8 to be on EBP precautions due to the presence of a foley catheter.

During an observation of a Restorative Nursing Aide program (nursing aide program that help residents maintain any progress made after therapy intervention to maintain their function) session on 3/12/2025 at 9:34 am, in Resident 8's room, Resident 8 was lying in bed. RNA 1 and RNA 2 entered Resident 8's room, put on gloves and did not put on isolation gowns. RNA 1 assisted Resident 8 with range of motion (ROM, full movement potential of a joint) exercises to the right arm and RNA 2 assisted Resident 8 with ROM exercises to the left arm. Once RNA 1 and RNA 2 completed exercises to Resident 8's both arms, RNA 1 and RNA 2 removed both gloves, washed hands, and exited the room.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 18 555070 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555070 B. Wing 03/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Southland 11701 Studebaker Road Norwalk, CA 90650

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During an interview on 3/12/2025 at 9:43 pm, RNA 1 and RNA 2 stated they did not wear isolation gowns while assisting Resident 8 with ROM exercises because they did not know Resident 8 was on EBP Level of Harm - Minimal harm or precautions. RNA 1 and RNA 2 stated they did not see the sign indicating Resident 8 was on EBP potential for actual harm precautions and did not see a PPE storage container upon entrance to Resident 8's room. RNA 1 and RNA 2 stated they should have worn isolation gowns while assisting Resident 8 with ROM exercises to both arms Residents Affected - Many because they had direct contact with Resident 8 who was on EBP precautions. RNA 1 and RNA 2 stated it was important to follow infection control protocols to prevent the spread of infection.

During an interview on 3/12/2025 at 10:14 am, the IPN stated the purpose of EBP was to reduce the transmission of MDRO. The IPN stated all staff providing direct patient care for residents on EBP precautions must wear the appropriate PPE which included an isolation gown and gloves to prevent the spread of infection and reduce the transmission of MRDO.

During an interview on 3/14/2025 at 1:27 pm, the DON stated it was important all staff followed the proper infection control protocols to prevent the spread of infection.

c. During a review of Resident 268's Admission Record (AR), the Admission Record indicated Resident 268 was admitted to the facility on [DATE REDACTED] with diagnoses including hyperlipidemia ( elevated level of fat in the blood), anxiety disorder ( feeling of worry anxiety and fear ) and difficulty in walking not elsewhere classified.

During a review of Resident 268's Minimum data Set (MDS- a resident assessment tool) dated 1/28/2025,

the MDS indicated Resident 268's cognition (thought process) was intact. The MDS indicated Resident 268 needs partial/moderate assistance ( helper lifts holds or supports trunk or limbs but provides less than half

the effort) with sit to lying, roll left to right and lying to sitting on side of bed and substantial /maximum assistance (helper lifts or holds trunk or limbs and provides more than half the effort) with toileting.

During a review of Resident 268's Order Summary Report(OSR), the OSR indicated active orders as of 3/4/2025, for a peripheral venous catheter .

During an observation and interview on 3/11/2025 at 11:46 a.m., with the Licensed Vocational Nurse 8 (LVN 8) in Resident 268' room , Resident 268 was noted with a peripheral venous catheter on her right hand with no pressure cap covering the hub, LVN 8 stated there should have been a pressure cap to cover the hub of

the catheter for infection control preventing pathogens from entering the hub.

During an interview on 3/12/2025 at 8:12 a.m., with the Registered Nurse 1 (RN 1) , RN 1 stated peripheral venous catheter needs to have a pressure cap at the end of the hub to prevent infection from going into the hub.

During an interview on 3/14/2025 at 11:20 a.m., with Director of Nursing (DON), the DON stated the peripheral venous catheter needs a pressure cap to prevent infection.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 18 555070 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555070 B. Wing 03/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Southland 11701 Studebaker Road Norwalk, CA 90650

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 d. During a review of Resident 26's Admission Record, the Admission Record indicated the facility admitted Resident 26 on 5/13/2022, and readmitted on [DATE REDACTED] with diagnoses including acute pulmonary edema (a Level of Harm - Minimal harm or condition where fluid accumulate in the lungs, leading to difficulty breathing) and COVID-19 (a respirator potential for actual harm illness caused by a virus, SARS-CoV-2, that spreads through droplets when infected people cough, sneeze, or talk, and can cause symptoms like fever, cough, and trouble breathing) added on 11/26/2024. Residents Affected - Many

During a review of Resident 26's MDS dated [DATE REDACTED], indicated Resident 26 had moderately impaired cognitive (functions your brain uses to think, pay attention, process information, and remember things). The MDS indicated Resident 26 required setup or clean-up assistance (helper assists only prior to or following

the activity) with eating, oral hygiene, hygiene, moderate assistance (helper does less than half the effort to complete the task) with toileting hygiene, and showering.

During a review of Resident 26's Order Summary Report, orders as of 3/11/2025, the Order Summary Report indicated the resident had diagnosis of COVID-19 again on 3/10/2025 and an order to place the transmission-based precaution (TBP- extra safety measures, used in addition to standard precautions, to prevent the spread of infections that can be transmitted): respiratory (measures taken to prevent the spread of diseases transmitted through the air by using PPE and special ventilation required prior to enter the room, such as a disposable gown, eye protection such as goggles or face shield, fit-tested respirator and gloves), droplet precautions (measures to prevent the spread of germs through tiny droplets released when someone coughs, sneezes, or talks) and contact precautions (measures takes to prevent the spread of germs though direct and indirect contact with a person or their environment) on 3/11/2025.

During a concurrent observation and interview on 3/11/2025 at 7:53 a.m. with Housekeeping Staff (HK) 1, at

the door of Resident 26's room, observed HK 1 entering the COVID precaution room wearing a mask and gloves but not wearing a gown and eye protection. HK 1 stated that wearing mask without other PPE is acceptable practice while bring supplies in without touching anything inside the COVID precaution room.

During a concurrent observation and interview on 3/11/2025 at 8:25 a.m. at the door of Resident 26's room, observed a Certified Nurse Assistant (CNA) 2 entering the room with mask and gloves holding the breakfast tray but not wearing a gown and eye protection. CNA 2 stated that she supposed to wear proper PPE prior to enter the COVID precaution room.

During a concurrent observation and interview on 3/12/2025 at 8:04 a.m. by Resident 26's room, observed HK 3 entering the room wearing a mask and gloves, HK 3 was observe touching the curtains inside the room

before exiting . HK 3 stated that wearing a mask and gloves without wearing a gown or eye protection was

an acceptable practice when entering the Covid precaution room. HK 3 stated that she forgot to sanitize hands prior to entering and leaving the room.

During a concurrent observation and interview on 3/12/2025 at 2:12 p.m. inside the Resident 26's room, CNA 3 and CNA 4 observed entering the room without wearing an eye protection. CNA 3 observed leaving the room and walked away from the room without sanitizing hands. CNA 3 stated that she did not sanitize her hand upon leaving the room. CNA 4 observed not changing mask upon leaving the room.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 18 555070 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555070 B. Wing 03/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Southland 11701 Studebaker Road Norwalk, CA 90650

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During an interview on 3/13/2025 at 12:43 a.m. with the Director of Nursing (DON), the DON stated that facility place contact, droplet and respiratory precautions upon identifying a COVID-19 resident to prevent the Level of Harm - Minimal harm or spread of infections. The DON stated that the proper donning (the act of putting on a garment or piece of potential for actual harm equipment) PPE included wearing face shield or goggles, gown, gloves, and proper doffing (taking off or removing something, especially clothing or protective gear, like a hat or gloves) PPE included changing the Residents Affected - Many mask upon leaving the room. The DON also stated hand sanitizing required prior to entering and upon leaving the precaution room.

e. During a review of Resident 7's Admission Record, the Admission Record indicated the facility admitted Resident 7 on 8/2/2024 , and readmitted on [DATE REDACTED] with diagnoses including dysphagia (swallowing difficulties), gastrostomy status (having a surgical opening made into the stomach, often to allow for feeding or medication delivery though a tube, known as a gastrostomy tube or G-tube) and chronic viral hepatitis C (a long-term liver infection).

During a review of Resident 7's MDS, dated [DATE REDACTED], indicated Resident 7 had severe impairment cognitive (functions your brain uses to think, pay attention, process information, and remember things). The MDS indicated Resident 7 was dependent (helper does all the effort) with oral hygiene, toileting hygiene, showering, dressings, and required maximal assistance (helper does more than half the effort to complete task) with personal hygiene.

During a review of Resident 7's Order Summary Report, orders as of 3/11/2025, the Order Summary Report indicated Enhanced Standard Precautions (know at Enhanced Barrier Precautions), for gastrostomy-tube (G-tube, a feeding tube inserted directly into the stomach) on 2/27/2025.

During an observation on 3/10/2025 at 2:26 p.m., in Resident 7's room, observed Licensed Vocational Nurse (LVN) 1 hung new Nepro (therapeutic nutrition) tube feeding at the pole and connecting it to Resident 7's G-tube. LVN 1 was wearing gloves, mask, but not wearing a gown on.

During an interview on 3/10/2025 at 2:41 a.m. with LVN 1, LVN 1 stated that she touched Resident 7 and changed the tube feeding without wearing a gown, although she supposed to wear one to prevent the spread of infections.

During a concurrent observation and interview on 3/10/2025 at 2:41 p.m. with Licensed Vocational Nurse (LVN) 1, at the door of Resident 7's room, no EBP sign on the door observed. LVN 1 stated that Resident 7 had a G-tube, the EBP sign should be posted but missing.

f. During a review of Resident 26's Admission Record, the Admission Record indicated the facility admitted Resident 26 on 5/13/2022 and readmitted on [DATE REDACTED] with diagnosis including acute pulmonary edema and COVID-19.

During a review of Resident 26's MDS dated [DATE REDACTED], indicated Resident 26 had moderately impaired. The MDS indicated Resident 26 required setup or clean-up with eating, oral hygiene, hygiene, moderate assistance with toileting hygiene, and showering.

During a review of Resident 26's Dermatopathology report, dated 2/3/2025, the report indicated that Resident 26' had scabies. The report also indicated the dermatologist will send topical permethrin (a medication used to treat treating scabies and lice).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 18 555070 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555070 B. Wing 03/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Southland 11701 Studebaker Road Norwalk, CA 90650

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During a review of Resident 26's Order Summary Report, orders as of 3/11/2025, the Order Summary Report indicated there was an order to place contact isolation related to scabies on 2/21/2025. Level of Harm - Minimal harm or potential for actual harm During an interview on 3/12/2025 at 11:50 a.m. with Registered Nurse (RN) 4 at Resident 26's dermatology office, RN 4 stated that Resident 26 had itchiness over her body, so the dermatologist took the sample from Residents Affected - Many the resident on 1/27/2025, got scabies report on 2/3/2025. RN 4 stated that the dermatologist sent a prescription regarding the scabies to the pharmacy on the same day, 2/3/2025. RN 4 also stated that she talked with Licensed Vocational Nurse (LVN) 7 regarding the positive result of scabies on 12/14/2025 to remind the facility.

During a review of the facility's pharmacy's prescription history, dated 1/31/2025 through 3/12/2025, the history indicated that the pharmacy dispensed permethrin (on 2/3/2025, 2/20/2025 and 2/26/2025.

During a concurrent interview and record review on 3/13/2025 at 9:15 a.m. with LVN 7, Resident 26's progress notes, for the month of January, February, and March were reviewed. The LVN 7 stated that Dermatologist progress note indicated that Resident 26 had rashes on the legs on 1/27/2025, RN 4 informed LVN 7 regarding scabies result on 2/14/2025, and LVN 7 informed the result to the Infection Prevention Nurse (IPN). The LVN 7 stated that scabies are contagious through contact, the facility should had placed

the resident on contact isolation on 2/3/2025 when the physician diagnosed the resident with scabies and ordered permethrin to prevent the spread of the disease, not only for the resident but also for the staff, visitors, and anyone who made contact with her or her linens. However, the facility placed the contact insolation on 2/17/2025.

During an interview on 3/13/2025 at 12:43 a.m. with the Director of Nursing (DON), the DON stated if scabies identified, it required to put contact isolation on the resident to prevent the spread of infection.

g. During a concurrent observation and interview on 3/12/2025 at 3:07 p.m. with the Housekeeping Supervisor (HKS), in clean linen area in the laundry room, multiple non-laundry items found on the shelves.

During an interview on 3/14/2025 at 11:18 a.m. with the Director of Nursing (DON), the DON stated that those items should not be there, the laundry area should be clean.

During a review of the facility's Policy and Procedure (P/P) titled, IPCP Standard and Transmission-Based Precautions, revised 3/2024, the P/P indicated it was the policy of the facility to implement infection control measures to prevent the spread of communicable diseases and conditions. The P/P indicated the use of gown and gloves for high contact resident care activities for residents on EBP precautions was indicated for residents with wounds and/or indwelling medical devices regardless of known MDRO infection or colonization and MDRO infection or colonization.

During a review of the facility's Policy and Procedure (P/P) titled, Dressing change and Care of Central Venous Catheter, undated indicates to reduce the risk of infection to the insertion or exit site and surrounding area of central venous catheters, including [NAME] , Broviac, [NAME] and percutaneous CVA. Quickly remove the old cap and attach the new cap to the catheter hub.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 18 555070 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555070 B. Wing 03/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Southland 11701 Studebaker Road Norwalk, CA 90650

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During a review of the facility's policy and procedure (P&P) titled, IPCP standard and transmission-based Precautions (TBP), revised 3/2024, the P&P indicated, the policy was to implement infection control Level of Harm - Minimal harm or measures to prevent the spread of communicable diseases and conditions. The P&P indicated 1. Standard potential for actual harm precautions apply to the care of all residents including hand hygiene, 2. Contact precautions required for patient who has ongoing transmission, staff must wear a gown and gloves for all interactions that may Residents Affected - Many involve contact with the patient or the patient's environment, 3. EBP include the use of gown and gloves

during high-contact resident care activities, such as device care or use: feeding tube, 4. Droplet Precautions include using PPE appropriately including donning mask (and eye protection if indicated) upon entry into the patient room, 6. Implementation include posting clear signage on the door or wall outside of the resident room indicating the type of precautions and required PPE.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 18 555070 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555070 B. Wing 03/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Southland 11701 Studebaker Road Norwalk, CA 90650

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Level of Harm - Minimal harm or 50387 potential for actual harm Based on observation, interview and record review the facility failed to maintain a pest-free environment Residents Affected - Many when a cockroach appeared in one of one sample resident's room (Resident 48's) .

This failure had the potential to compromise the provision of a clean and homelike environment to residents.

Findings:

During a concurrent observation and interview on 3/10/2025 at 2:15 p.m. with Housekeeping Staff (HS) 2, in Resident 48's room, observed a bug crawling in the room. HS 2 entered and found the bug in the resident's rest room. HS 2 stated that she had observed it before; sometimes it comes from window, and sometimes from the sink.

During an interview on 3/12/2025 at 7:45 a.m. with the Administrator (Admin), the Admin stated that the bug was a type of cockroach and it should not be there.

During an interview on 3/14/2025 at 11:18 a.m. with the Director of Nursing (DON), the DON stated that no pest should be inside the room, it was not clean or safe environment, residents' room should be kept clean and homelike.

During a review of the facility's policy and procedure (P&P) titled, Pest Control, reviewed 7/2023, the P&P indicated, the facility to provide a clean environment and take all reasonable efforts to control pests.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 18 555070

F-F610

Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 18 555070 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555070 B. Wing 03/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Southland 11701 Studebaker Road Norwalk, CA 90650

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Respond appropriately to all alleged violations.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44055 potential for actual harm Based on interview and record review, the facility failed to thoroughly investigate and submit the investigation Residents Affected - Some report of all allegations of abuse to the California Department of Public Health (CDPH) within five days of the incident.

a) The facility failed to thoroughly investigate and submit investigative reports to CDPH when an allegation of abuse was made on 11/15/2024 by Family Member (FM)2 that an unidentified Certified Nurse Assistant (CNA), unidentified, took Resident 76's cell phone, closed Resident 76's door, and turned the television on loud and Resident 76 felt isolated.

b) The facility failed to thoroughly investigate and submit investigative reports to CDPH when an allegation of abuse was made, approximately one week (unspecified date) after an incident that occured on 2/23/2025, by FM 2 that a male resident (Resident 167), who did not have pants on, entered Resident 76's room and allegedly kissed Resident 76's arm without Resident 76's consent.

This deficient practice resulted in CDPH's inability to investigate the allegation of abuse timely and had the potential for other allegations of abuse to go unreported.

Findings:

During a review of Resident 76's Admission Record, the Admission Record indicated Resident 76 was originally admitted to the facility on [DATE REDACTED] with diagnoses including metabolic encephalopathy (change of how brain works due to an underlying condition), colostomy status (a surgical procedure that brings one end of the large intestine out through the abdominal wall to allow waste to leave the body), and bilateral primary osteoarthritis of the knee (a type of arthritis on both knees that occurs when the cartilage on the ends of bones wears down, causing the bones to rub against one another).

During a review of Resident 76's Minimum Data Set (MDS), resident assessment tool, dated 10/30/2024, the MDS indicated Resident 76's cognition (thought process) was severely impaired. The MDS indicated Resident 76 needed set up assistance when eating, supervision (helper provides verbal cues and assistance may be given during activity) with oral hygiene, upper body dressing, personal hygiene, and moderate assistance (helper does less than half the effort) with toileting hygiene, showering, lower body dressing, and putting on/taking off footwear.

During a review of Resident 167's Admission Record, the Admission record indicated Resident 167 was admitted to the facility on [DATE REDACTED] with diagnoses including metabolic encephalopathy, cognitive communication deficit, and multiple myeloma (blood cancer).

During a review of Resident 167's MDS, dated [DATE REDACTED], the MDS indicated Resident 167's cognition was severely impaired. The MDS indicated the resident needed supervision with eating and oral hygiene, moderate assistance with dressing, and maximal assistance (helper does more than half the effort) with toileting hygiene and showering.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 18 555070 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555070 B. Wing 03/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Southland 11701 Studebaker Road Norwalk, CA 90650

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 During a phone interview on 3/11/2025 at 12 p.m., with FM 2, FM 2 stated on 2/23/2025 (no time of day given) a man (Resident 167) was kissing Resident 76's arm. FM2 stated Resident 167 had no pants on. Level of Harm - Minimal harm or potential for actual harm During an interview on 3/11/2025 at 3:34 p.m. with CNA 1, CNA 1 stated, on 2/23/2025, CNA 9 informed CNA 1 to watch Resident 167 closely because she heard Resident 167 went into Resident 76's room and Residents Affected - Some gave Resident 76 a kiss.

During a phone interview on 3/11/2025 at 3:49 p.m., with Registered Nurse (RN)2, RN 2 stated on 2/23/2025 at around 7:30 a.m. Resident 167 was found sitting on a chair inside Resident 76's room just wearing a hospital gown and disposable underwear. RN 2 stated Resident's 76 and 167 were immediately separated. RN 2 stated she was not aware that Resident 167 had just kissed Resident 76 without consent prior to her finding him in Resident 76's room. RN 2 stated one-week later FM 2 informed RN 2 that a man went in Resident 76's room and kissed Resident 76. RN 2 stated RN 2 should have reported the incident to the administrator and Resident 76 should have been assessed, monitored, provided with emotional support, and

the physician should have been notified of the allegations of abuse.

During an interview on 3/12/2025 at 12:03 p.m., with the Social Services Director (SSD), the SSD stated the incident that allegedly occurred on 2/23/2025 should have been reported to the SSD, administrator, or the Director of Nursing. The SSD stated the incident should have been thoroughly investigated then results submitted to the agencies.

During a review of a document titled, Grievance Resolution Form, dated 11/15/2024, the Grievance Resolution Form completed by Resident 76's FM 2 indicated a grievance was made regarding an unnamed CNA taking Resident 76's phone, closing the door on Resident76, and turning the television in Resident 76's room loud.

During an interview on 3/13/2025 at 11:32 a.m., with the Social Services Director (SSD), the SSD stated the grievance filed 11/15/2024 should have been reported to CDPH, ombudsman, and local law enforcement within 2 hours of the incident and investigated thoroughly and reports submitted within 5 days of the incident.

During an interview on 3/14/2025 at 11:18 a.m., with the Director of Nursing (DON), the DON stated all allegations of abuse need to re reported to CDPH, ombudsman, and the police and thoroughly investigated and submitted to the agencies.

During an interview on 3/14/2025 at 1:44 p.m., with the Administrator (ADMIN), the ADMIN stated all allegations of abuse need to be reported as soon as possible and preventative measures implemented. The investigation needs to be thorough and submitted to the agencies involved.

During a review of the facility's policy and procedure (P&P) titled, Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment, revised 10/2022, the P&P indicated All reports of resident abuse and neglect shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported to

the state agency within five working days of the incident.

Cross reference